NEW CLIENT INTAKE FORM
Please take a moment to fill out this intake form prior to your first hypnotherapy or coaching session.
By completing and submitting this form, you affirm that you have read and understood the "Acknowledgement of Services & Disclosure" and consent to the services, fees and audio recording procedure as outlined by Michele Guzy, C.Ht.
Acknowledgement of Services & Disclosure
In recognition that millions of Californians receive a substantial volume of healthcare services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials.
The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code. The purpose of a program of hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state. A certified hypnotherapist is not a licensed physician or psychologist, and hypnotherapy services are not licensed by the State of California. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures.
Hypnosis works with the power of the subconscious mind to change habits and behaviors. During hypnotherapy sessions, clients remain completely aware of everything that is going on. Many people experience a hyper-awareness where sensations are perceived and the ability to visualize or imagine is enhanced. In some cases, it might be necessary for a Hypnotherapist to respectfully touch a client's head, shoulder, arm, wrist, hand, feet or leg to assist in relaxation or specific technique.
The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client.
While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. The court may order disclosure of information learned in therapy. The client herewith will not hold the above responsible in any way, nor shall any claims be valid in reference to such methods, instructions and programs in the teaching of relaxation and behavior modification self-improvement.
A hypnotherapist will to the best of their ability to accomplish the objectives as quickly as possible during the sessions. While hypnosis may be an effective technique for many purposes, the effectiveness may vary for each person and no specific results, or progress can be promised or guaranteed.
SESSION FEES & PACKAGES:
A phone consultation is offered to new clients to discuss all services and fees. Successful conditioning may include an undetermined number of sessions based on individual needs and personal results may vary.
CORE HYPNOTHERAPY:
This is best for single session counseling that quickly shifts neural pathways in the brain and installs new behaviors.
TRANCE-FORMATIONAL PACKAGES:
These discount packages are to be paid in full before or after the 1st session. Packages INCLUDE your 1st Core Hypnosis Session and must be completed within a (6-month period) and cannot be transferred to another person or family member without prior permission.
PAYMENT OPTIONS:
I agree to pay for all services at the current therapy and coaching rate (subject to change) by Cash, Venmo, Paypal, Zelle or Credit Card. I agree to give (24) hour notice by phone or text for any changes to appointment times. Missed appointments without prior notice or a cancellation (less than 24 hours) will result in full rate charge or the loss of a pre-paid session.
AUDIO RECORDINGS:
Michele Guzy records the hypnosis portion of all hypnotherapy sessions. These Audio Recordings are made during live sessions combined with music and are available to clients when requested for personal use. Audio Recordings may also be chosen by Michele to be included in the hypnosis section of the "Hypnotic Hub Membership Program". They will be professionally edited to a generic version and modified for self-improvement and teaching modules. Audio Recordings that are chosen for the Hypnotic Hub will not disclose any private information, client's name, personal history or verbal responses.